Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual GP care for patients with depression. II: Cost effectiveness

National Primary Care Research and Development Centre (NPCRDC), University of Manchester, UK.
BMJ Clinical Research (Impact Factor: 14.09). 01/2001; 321(7273):1389-92. DOI: 10.1136/bmj.321.7273.1389
Source: PubMed


To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.
Prospective, controlled trial with randomised and patient preference allocation arms.
General practices in London and greater Manchester.
464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.
Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.
Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production.
197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. At four months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either four or 12 months. Sensitivity analyses did not suggest that the results depended on particular assumptions in the statistical analysis.
Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. There are no significant differences between treatments in either outcomes or costs at 12 months.

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    • "Not surprisingly, psychological approaches such as CBT have been particularly effective in treating depression in medical patients who need help addressing maladaptive beliefs about their illness that initiate and maintain depression (Bower et al., 2000; Kessler et al., 2009; Serfaty et al., 2009; Ward et al., 2000). Most studies in primary care patients have compared CBTwith control conditions such as " usual care " by the physician, a " talking control " condition, or alternative forms of therapy such as nondirective counseling (Bower et al., 2000; Katon et al., 1996; Kessler et al., 2009; Serfaty et al., 2009; Ward et al., 2000). Head-to-head comparisons of varying forms of CBT are rare. "
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    ABSTRACT: We examine the efficacy of conventional cognitive behavioral therapy (CCBT) versus religiously integrated CBT (RCBT) in persons with major depression and chronic medical illness. Participants were randomized to either CCBT (n = 67) or RCBT (n = 65). The intervention in both groups consisted of ten 50-minute sessions delivered remotely during 12 weeks (94% by telephone). Adherence to treatment was similar, except in more religious participants in whom adherence to RCBT was slightly greater (85.7% vs. 65.9%, p = 0.10). The intention-to-treat analysis at 12 weeks indicated no significant difference in outcome between the two groups (B = 0.33; SE, 1.80; p = 0.86). Response rates and remission rates were also similar. Overall religiosity interacted with treatment group (B = -0.10; SE, 0.05; p = 0.048), suggesting that RCBT was slightly more efficacious in the more religious participants. These preliminary findings suggest that CCBT and RCBT are equivalent treatments of major depression in persons with chronic medical illness. Efficacy, as well as adherence, may be affected by client religiosity.
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    • "We will collect participants’ use of BA and CBT from clinical records, with information on additional resources involved (for example, training, preparation, supervision and so forth) collected directly from therapists. We will measure all other health and social care services used, including medication prescription and use, and productivity losses using the Adult Service Use Schedule, designed on the basis of previous evidence of service use in depressed populations [42]. We will also measure productivity losses using the absenteeism and presenteeism questions of the World Health Organization’s Heath and Work Performance Questionnaire [43]. "
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    ABSTRACT: Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers. COBRA is a two-arm, non-inferiority, patient-level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists to BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT. Four hundred and forty patients with major depressive disorder will be recruited through screening in primary care. We will analyse for non-inferiority in per-protocol and intention-to-treat populations. Our primary outcome will be severity of depression symptoms (Patient Health Questionnaire-9) at 12 months follow-up. Secondary outcomes will be clinically significant change and severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health-related quality of life (Short-Form Health Survey-36) at 12 and 18 months. Our economic evaluation will take the United Kingdom National Health Service/Personal Social Services perspective to include costs of the interventions, health and social care services used, plus productivity losses. Cost-effectiveness will explored in terms of quality-adjusted life years using the EuroQol-5D measure of health-related quality of life. The clinical and economic outcomes of this trial will provide the evidence to help policy makers, clinicians and guideline developers decide on the merits of including BA as a first-line treatment of depression.Trial registration: Current Controlled Trials ISRCTN27473954.
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    • "Our study suggests a qualification, as the effect was only observed for pharmacological treatment, and not for psychological treatment, as dropout from BA was not influenced by preference. The finding that differences between BA and pharmacotherapy in outcome as assessed with the HRSD was moderated by preference are in line with four previous studies reporting effects of preference on outcome (Kocsis et al., 2009; Mergl et al., 2011; Patricia et al., 2005; Steidtmann et al., 2012), but in contrast to the seven studies that did not find such effects (Bedi et al., 2000; Dunlop et al., 2012; Kwan et al., 2010; Laykin et al., 2007; Raue et al., 2009; Van et al., 2009; Ward et al., 2000). It is unclear which factors might explain the different findings across studies, but these might include differences between samples (e.g., primary vs. secondary care), differences between treatments that were compared, differences in designs, and different assessment methods of preferences. "
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